Injury of unsp nerve at shldr/up arm, unsp arm, sequela

This code signifies a long-term or late effect of an unspecified nerve injury affecting the shoulder or upper arm. The specific nerve involved is not documented, nor is the affected arm specified. This diagnosis indicates that the initial injury has resolved, but the patient continues to experience residual symptoms or complications.

Apply this code when documentation clearly indicates a sequela (e.g., chronic pain, weakness, paresthesia) resulting from a past, unspecified nerve injury in the shoulder or upper arm. This is appropriate when the original injury's acute phase has passed, and the patient is being treated for the lasting effects. Use this code when laterality and the specific nerve are not documented.

• Always assign a sequela code (ending in "S") as a secondary diagnosis, following the code for the primary condition or symptom being treated.
• Ensure the medical record explicitly states "sequela," "late effect," or similar terminology to justify the "S" seventh character.
• Avoid using this code if the specific nerve or laterality is known; instead, seek a more precise code from the S44 category.